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Hybrid Imaging

Cardiology Update 2015

Davos, Switzerland

Oliver Gaemperli, MD Interventional Cardiology and Cardiac Imaging

University Hospital Zurich

Switzerland

Disclosures

• Speaker honoraria:

- Astra Zeneca, Abbott Vascular, GE Healthcare, Guerbet

• Consultant fees:

- Abbott Vascular

• Research grant:

- Abbott Vascular

2015 Davos Cardiology Update, Page 3

Pathophysiological basis for anatomo-functional imaging: Disagreement between coronary morphology and perfusion

White CW. NEJM 1984 Intraoperative Doppler flow

Uren NG. NEJM 1994 15O-H2O PET

Tonino PA et al. JACC 2010 Fractional flow reserve

„different techniques... ...same results“


Neither QCA nor CTCA predict the functional significance of

coronary lesions

Meijboom et al. J Am Coll Cardiol. 2008;52:636

Visual analysis: CCA: <50%; CTCA: <50% Quantitative analysis: QCA: 44%; QCT: 40% FFR=0.70

Pathophysiological basis for anatomo-functional imaging:

http://content.onlinejacc.org/content/vol52/issue8/images/large/08019384.gr1.jpeg

http://content.onlinejacc.org/content/vol52/issue8/images/large/08019384.gr2.jpeg


„When it comes to outcome, flow always trumps anatomy“

COURAGE

Boden WE. NEJM 2007;356:1503

COURAGE Nucl substudy

Circulation. 2008 Mar 11;117(10):1283-91

ANATOMY FLOW


De Bruyne B et al. N Engl J Med 2012;367:991-1001

FAME II


Dedicated software packages

64-slice CT

2001

2005 1999

2005 2007

2007

2010

Prospective ECG triggering 2-3 mSv

Iterative reconstruction algorithms <1mSv

2014

Feasibility of hybrid PET/CTCA (Zurich)

COURAGE ICA+ SPECT Hybrid (Schindler TH)

EVINCI

EVINCI

Timeline/Developments of Cardiac Hybrid Imaging

2013

FAME II

Hybrid devices


56 yo lady, atypical chest pain, Fam. Hx of CAD, inconclusive stress test


Hybrid SPECT/CTCA


Diagnostic accuracy of cardiac hybrid imaging (SPECT/CTCA and PET/CTCA)

Author Hybrid

system N Gold standard (definition of

significant CAD) Sens Spec PPV NPV

Namdar et al.

2005

13N-NH3 PET/ 4-slice

CTCA 25 Flow-limiting coronary stenoses requiring

revascularization (ICA +PET) 90 98 82 99

Rispler et al. 2007 SPECT/16-slice

CTCA 56 Flow-limiting coronary stenoses (>50%

stenosis on ICA + SPECT pos.) 96 95 77 99

Groves et al. 2009 82Rb PET/ 64-slice

CTCA 33 >50% stenosis on ICA 88 100 97 99

Sato et al.

2010 SPECT/64-slice

CTCA* 130 >50% stenosis on ICA 94 92 85 97

Kajander et al.

2010

15O-H2O PET/64-slice

CTCA 107 Flow-limiting coronary stenosis (>50%

stenosis of ICA + FFR) 93 99 96 99

Schaap et al. 2013 SPECT/64-slice

CTCA 98 Flow-limiting coronary stenosis (>50%


Danad et al.

2013¶


CTCA

120 Flow-limiting coronary stenosis (>50%


Thomassen et al.

2013


CTCA

44 >50% stenosis on ICA (QCA) 91 100 100 92

Dong et al.

2014

SPECT/64-slice

CTCA 78 Flow-limiting coronary stenoses (>50%

stenosis on ICA + SPECT pos.) 94 72 88 86

*Hybrid SPECT/CTCA only applied for non-evaluable arteries on CTCA (14%)

¶Non-fused images

Adapted from Gaemperli O et al. EHJ 2011


Incremental prognostic value of CT angio and MPI

van Werkhoven JM, et al. JACC 2009;53:623

MSCT <50% and MPI normal

MSCT <50% and MPI abnormal*

MSCT ≥50% and MPI normal

MSCT ≥50% and MPI abnormal*

* MPI abnormal = SSS ≥ 4

Patients at risk 439 423 386 354 299 243

Log-rank test: p<0.005

0

0.5

1

0 125 250 375 500 625

Follow-up (days)

Su

rviv

al

free

of

dea

th o

r M

I


Prognostic value of cardiac hybrid imaging with SPECT/CTCA

Patients

at risk

Log-rank p<0.001

Matched

Unmatched

1.0

0.8

0.9

0.6

0.7

Normal

Follow-up (Years)

Su

rviv

al

Fre

e o

f H

ard

Eve

nts

Log-rank p<0.005

1.0 2.0 3.0 4.0 0.0

286.0 211.0 128.0 26.0 302.0

Su

rviv

al

Fre

e o

f M

AC

E

1.0 2.0 3.0 4.0 0.0

Follow-up (Years)

274.0 196.0 117.0 26.0 302.0

Unmatched

Matched

Normal 1.0

0.8

0.6

0.4

0.2

0.0

Pazhenkottil et al. EHJ 2011; Jun;32(12):1465-71

n=335 patients


Impact of hybrid imaging on patient management

Pazhenkottil et al. Eur Heart J. 2011 Nov;32(22):2824-9).

0%

11%

41%

Schaap J et al. Heart. 2013 Feb;99(3):188-94.


Hybrid anatomo-functional imaging put into clinical practice

• Small studies indicate diagnostic and prognostic value of hybrid imaging for stable CAD patients

• But increased radiation and costs have to be considered!

• It is unclear which patients may derive benefit from hybrid imaging procedures

• Until we have more data, a reasonable approach to use of hybrid imaging should be practiced (CTO? MVD? Intermediate PTP?)


New developments of Hybrid imaging

• CTFFR, CT Perfusion (CTP)

• Stress CMR/CT

• PET/CMR

• 3D Echo/CT?

• Real-time hybrid imaging


Non-invasive FFR (FFRCT)

3-D FFRCT map computed

FFRCT = 0.72

(can select any

point on model)

Computational Model

based on CCTA Calculate FFRCT

No additional imaging

No additional medications

3-D anatomic model from CCTA

Blood flow equations solved on

supercomputer

Blood Flow Solution

Physiologic models

-Myocardial demand

-Morphometry-based boundary condition

-Effect of adenosine on microcirculation


DISCOVER-FLOW

Non-inferiority Endpoint: Diagnostic Accuracy significantly over 70% (such that the lower boundary of the 1-sided 95%

confidence interval of this estimate exceeded 70%):

Not met! DA 73% (95% CI, 67%-78%)

81 86

79

65

93

53

94

34 40

92

0

10

20

30

40

50

60

70

80

90

100

Accuracy Sensitivity Specificity PPV NPV

FFR-CT CTCA only

HeartFlow-NXT

N=254, *p<.05


CT perfusion (+CTCA) – one stop-shop CT

• Is generally obtained

with adenosine-stress

• CT scanners with ability

for 1-beat acquisition

are preferred (320-slice,

128 DSCT)

• Obtained at the cost of

higher radiation

exposure (depending on

the scan protocol) and

contrast agent use

Ko BS et al. EHJ 2012;33:67–77

320-row detector CT scanner (Aquilion ONE, Toshiba Medical

Systems, Japan

2015 Davos Cardiology Update, Page 69 Presented at 2012 annual ESC meeting, published EHJ 2013


PET/CMR: Potential for use in cardiology LG CMR 13N-NH3 PET/CMR 18F-FDG PET/CMR

Assessment of scar, microvascular obstruction, perfusion and metabolic activity in affected myocar-dium after acute MI

Rischpler & Nekolla. Radiologe 2013;53:691–698 Nensa et al. Eur Heart J 2014;35: 2173

Assessment of inflam-matory or infiltrative myocardial disease (e.g. sarcoidosis, myocarditis (see right)

LG CMR 18F-FDG PET/CMR (with myocardial glucose uptake suppression)

T2-weighted CMR (edema)


Real-time Fusion of fluoroscopy with TEE during percutaneous SHD procedure

Echo Nav

Courtesy of Prof. R, Corti, Herzzentrum Hirslanden, Zurich


Summary

Assessment of coronary morphology AND myocardial perfusion is crucial for

appropriate management of stable CAD

Hybrid Imaging allows to identify flow-limiting coronary lesions („culprit

lesions“) requiring revascularization and may be particularyl helpful in

selected patients (intermediate PTP, MVD, CTO)

Provides independent prognostic information through combination and

coregistration of morphological and functional criteria

Novel modalities are available for hybrid imaging offering potential

advantages (radiation, resolution, etc.) and novel applications (real-time

hybrid, diseases other than CAD)


Thank You

PD Dr. med. Oliver Gaemperli Interventional Cardiology and Cardiac Imaging

Cardiovascular Center,

University Hospital Zurich,

Switzerland

[email protected]

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